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ICD-10-CM: Delayed But Not Dead

Teaching the Provider ICD-10

Faculty:

John F. Burns, CPMA, CPC, CPC-I, CEMC

AHIMA ICD-10 Ambassador and Trainer

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Agenda & Housekeeping

• ICD background and history

• Official Reporting Guidelines

o These 32 pages provide guidance to ICD-10-CM code use

• Auditing and Communicating Information Toward Clinical

Documentation Improvements

• Some exercises

You will notice throughout the slide deck that AHIMA slides

are the primary source. AHIMA Ambassadors are permitted

to use the training materials but are not permitted to make

any changes to the slides in appearance or content.

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ICD-10 For the Provider

• Run ICD-9-CM utilization and “map”

out ICD-10-CM equivalents

• Perform some internal audits of

common claims to determine the

extent of education that will be

necessary

• Provide education for providers that

specifically address their discipline(s)

o No sense taking OB with an Orthopedist

o There are 21 chapters in ICD-10, not all

will apply to everyone

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ICD-10 From The Auditor’s

Perspective • Consider the following:

o Laterality

• Some codes can be bilateral

(e.g., injectons/x-rays)

o External causes of injury

• For fractures, the specific type

(e.g. traumatic) must be documented

o Activity codes

o Place of occurrence codes

o Severity

o If it’s not documented as treated,

it should not be coded either, right?

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ICD-10-CM Background

• International Classification of Disease (ICD) has been

around since 1893

o 1948: WHO took over

o 1970s (late): US has used ICD-9-CM

1988: Required on claims

• Used in many other countries around the world since 1994

• HHS announced October 1, 2015 compliance deadline

o H.R. 4302, Protecting Access to Medicare Act of 2014

• In the US, ICD-10 codes have been used for reporting

mortality on death certificates since 1999

• According to WHO, ICD-11 is already in the works and will

be completed in 2015…hmmmm

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ICD-10-CM vs. ICD-9-CM

• 68,000+ ICD-10-CM codes compared to 13,000+ in ICD-9-CM

• 21 chapters in ICD-10-CM compared to 17 in ICD-9-CM

• ICD-10-CM codes are 3-7 characters compared to 3-5 digits

in ICD-9-CM

o All alpha characters used (except letter “U”)

• Expanded injury codes

o External causes and places of occurrence

• Greater specificity

o Laterality and granularity

• V-codes and E-codes are assigned in applicable chapters

• Combination codes (diagnosis/symptom)

• Documentation will be critical for accurate code assignment

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The Tabular List

• Categories (3 characters)

o Subcategories

Codes

• All Categories are 3 characters (decimal follows)

o A 3-character category without 4th/5th is a reportable code

J17 (Pneumonia in diseases classified elsewhere)

Be aware of “Code first underlying disease”

• A code with an applicable 7th character is invalid without the 7th

character…use an “X” placeholder

o Placeholders are common with fractures, injuries, external causes,

maternal care, labor and delivery, glaucoma, etc.

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X X X X

Category

. Etiology, anatomic

site, severity

Added 7th character for obstetrics, injuries, and external causes of injury

X X X A M S 0 2 6 . 5 x A

Additional

Characters

Alpha

(Except

U)

2 Numeric

3-7 Numeric or Alpha

3–7 Characters

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Coding in ICD-10-CM ICD-9-CM ICD-10-CM

Three to five characters Three to seven characters

First digit is numeric but can be alpha

(E or V)

First character always alpha

2–5 are numeric All letters used except U

Always at least three digits Character 2 always numeric: 3–7 can

be alpha or numeric

Decimal placed after the first three

characters (or with E codes, placed after

the first four characters)

Always at least three digits

Alpha characters are not case-sensitive Decimal placed after the first three

characters

Alpha characters are not case-sensitive

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The first character of an ICD-10-CM code is:

Answer: Always a letter

Rationale: This is an ICD-10-CM convention with all codes beginning

with a letter of the alphabet except the letter U.

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If an encounter is solely for chemotherapy, immunotherapy, or

radiation therapy for a neoplastic condition, the first reported

diagnosis is:

Answer:The appropriate Z51 code

Rationale: If a patient admission or encounter is solely for the

administration of chemotherapy, immunotherapy, or radiation

therapy assign code Z51.0, Encounter for antineoplastic radiation

therapy; or Z51.11, Encounter for antineoplastic chemotherapy; or

Z51.12, Encounter for antineoplastic immunotherapy as the first-

listed or principal diagnosis. If a patient receives more than one of

these therapies during the same admission more than one of these

codes may be assigned, in any sequence (ICD-10-CM Coding

Guideline I.C.2.e.2). An encounter for chemotherapy and

immunotherapy for a nonneoplastic condition should be coded to the

condition.

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True or false? When assigning the principal diagnosis for a patient

with AIDS, the AIDS code would always be sequenced before any

other conditions.

Answer: False

Rationale: When a patient is admitted with an HIV-related

condition, the principal diagnosis should be B20, Human

immunodeficiency virus [HIV] disease, followed by additional

diagnosis codes for all reported HIV-related conditions (ICD-10-CM

Coding Guideline I.C.1.a.2.a). When a patient with HIV disease is

admitted for an unrelated condition, for example, trauma, the code

for the unrelated condition should be the principal diagnosis with

B20 listed as an additional code (ICD-10-CM Coding Guideline

I.C.1.a.2.b).

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A patient has liver metastasis due to adenocarcinoma of the rectum

which was resected two years ago. The patient has been receiving

radiotherapy to the liver with some relief of pain. The patient is

being admitted at this time for management of severe anemia due

to the malignancy. The principal diagnosis listed on this admission

is:

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Answer: Liver metastasis

Rationale: When an admission or encounter is for the

management of an anemia associated with the malignancy, and the

treatment is only for anemia, the appropriate code for the

malignancy is sequenced as the principal or first listed diagnosis

followed by the appropriate code for the anemia (such as D63.0,

Anemia in neoplastic disease)

(ICD-10-CM Coding Guideline I.C.2.c.1). In addition, in the Tabular,

the note under D63.0 states to code first neoplasm (C00-D49).

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True or false? A fracture not described as“displaced” or “not

displaced” by default should be coded as “not displaced.”

Answer: False

Rationale: A fracture not indicated whether displaced or not

displaced should be coded to displaced (ICD-10-CM Coding

Guideline I.C.19.c). This information is also available in notes in the

Tabular (see category S52). A fracture not described as open or

closed is coded to the default of closed.

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True or false? A place of occurrence code should be used only at

the initial encounter for treatment.

Answer: True

Rationale: Codes from category Y92, Place of occurrence

of the external cause, are secondary codes for use after other

external cause codes to identify the location of the patient at the

time of injury. A place of occurrence code is used only once, at the

initial encounter for treatment and only one code from Y92 should

be recorded. A place of occurrence code should be used in

conjunction with an activity code, Y93. Only one code from Y93

should be recorded on a medical record (ICD-10-CM Coding

Guidelines I.C.20.b and c).

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In ICD-10-CM, diabetes mellitus codes include:

a. Type of diabetes

b. Body system affected

c. Complications affecting that body system

d. All of the above

Answer: d. All of the above

Rationale: The diabetes mellitus codes are combination codes

that include the type of diabetes mellitus, the body system affected

and the complications affecting that body system (ICD-10-CM

Coding Guideline I.C.4.a).

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True or False? Patients with a prior diagnosis of an HIV-related

illness should be assigned the code for AIDS (B20) on every

subsequent admission.

Answer: True

Rationale: Patients with any known prior diagnosis of an HIV-related

illness should be coded to B20. Once a patient has developed an

HIV-related illness, the patient should always be assigned code B20

on every subsequent admission or encounter. Patients previously

diagnosed with any HIV illness (B20) should never be assigned to

R75 or Z21, Asymptomatic human immunodeficiency virus [HIV]

infection status (ICD-10-CM Coding Guideline I.C.1.a.2.f).

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When an OB patient enters the hospital for complications of

pregnancy during one trimester and remains in the hospital into a

subsequent trimester, the final character selected for the

antepartum conditions should be:

a. For the trimester in which the complication first occurred

b. The trimester in which the patient was discharged

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Answer: a. For the trimester in which the complication first

occurred

Rationale: ICD-10-CM Coding Guideline I.C.15.a.4. states

in the instances when a patient is admitted to a hospital for

complications of pregnancy during one trimester and remains in the

hospital into a subsequent trimester, the trimester character for the

antepartum complication code should be assigned on the basis of

the trimester when the complication developed, not the trimester of

the discharge. If the condition developed prior to the current

admission

or encounter or represents a pre-existing condition, the trimester

character for the trimester at the time of the admission or encounter

should be assigned.

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When a patient seeks medical attention for an injury that occurred

several days prior to the medical encounter, what is the appropriate

seventh character to use?

Answer: A, initial encounter

Rationale: Seventh character A, initial encounter, is used while the

patient is receiving active treatment for the condition. Seventh

character D, subsequent encounter, is used for encounters after the

patient has received active treatment for the condition and is

receiving routine care for the condition during the healing or

recovery phase. Seventh character S, sequela, is used for

complications or conditions that arise as a direct result of a

condition (ICD-10-CM Coding Guideline I.C.19.a).

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• A primary malignant neoplasm overlapping two or more

contiguous (next to each other) sites should be classified to the

subcategory/code .8 (overlapping lesion), unless the

combination is specifically indexed elsewhere.

• For multiple neoplasms of the same site that are not contiguous,

such as tumors in different quadrants of the same breast, codes

for each site should be assigned.

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Neoplasms (C00-D49)

The diagnosis for this 61 year old female patient is small cell carcinoma of

the right lower lobe of the lung with metastasis to the intrathoracic lymph

node, brain, and right rib.

What are the diagnosis codes assigned?

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C34.31 Carcinoma, see also Neoplasm, by site,malignant.Refer to

Neoplasm Table, by site(lung), malignant, primary site, lower lobe

C77.1 Refer to Neoplasm Table, by site, lymph gland, malignant,

intrathoracic, secondary site

C79.31 Refer to Neoplasm Table, by site, brain, malignant,

secondary site

C79.51 Refer to Neoplasm Table, by site, bone, malignant, rib,

secondary site

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Diabetes mellitus

• Combination codes

• No longer classified as controlled

or uncontrolled

• Inadequately, out of control or

poorly controlled coded by type

with hyperglycemia

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Diabetes Coding

(E00-E89)

This 62 year old male is being seen for mild nonproliferative

diabetic retinopathy with macular edema. He has type II DM and

takes insulin on a daily basis. He also has diabetic cataract in his

right eye.

What diagnosis codes are assigned?

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E11.321Diabetes, diabetic (mellitus) (sugar), type 2, with,

retinopathy, nonproliferative, mild, with macular edema

E11.36Diabetes, diabetic (mellitus) (sugar), type 2, with, cataract

Z79.4Long-term (current) (prophylactic) drug therapy(use of),

insulin

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Diseases of the ear

(H60-H95)

A five year old female is seen for acute ear pain. Examination reveals

left acute serous otitis media. Further examination revealed a total

perforated tympanic membrane of the right ear due to chronic otitis

media.

What diagnosis codes are assigned?

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H65.02Otitis (acute), media (hemorrhagic)(staphylococcal)

(streptococcal) acute, subacuteserous – see Otitis, media,

nonsuppurative, acute, serous.Otitis media, nonsuppurative, acute

or subacute, serous

H66.91Otitis (acute), media (hemorrhagic) (staphylococcal)

(streptococcal), chronic

H72.821Perforation, perforated (nontraumatic) (of), tympanum,

tympanic (membrane) (persistent post-traumatic)

(postinflammatory), total

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• Type of hypertension not used

as an axis

• Acute MI codes changed from

8 weeks to 4 weeks or less

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Hypertension Example

A patient is seen today in follow-up for his benign hypertension.

What is the correct diagnosis code?

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I10Hypertension, hypertensive, (accelerated)(benign) (essential)

(idiopathic) (malignant) (systemic)

Rationale: ICD-10-CM does not differentiate between benign and

malignant hypertension.

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Hypertension with complications

Stage 3 chronic kidney disease with congestive heart failure (CHF) due to

hypertension.

What diagnosis codes are assigned?

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I13.0 Hypertension, hypertensive, (accelerated)(benign)

(essential) (idiopathic) (malignant)(systemic), cardiorenal

(disease), with heart failure, with stage 1 through stage 4 chronic

kidney disease

I50.9 Failure, failed, heart (acute) (senile) (sudden), congestive

(compensated) (decompensated)

N18.3 Disease, diseased, kidney (functional) (pelvis), chronic,

stage 3 (moderate)

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COPD

A patient has increasing shortness of breath, weakness, and

ineffective cough. Treatment included oxygen therapy and advice

for smoking cessation. Diagnosis listed as acute respiratory

insufficiency due to acute exacerbation of COPD and tobacco

dependence.

What diagnosis codes are assigned?

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J44.1 Disease, diseased, pulmonary, chronic obstructive, with

exacerbation (acute)

F17.200 Dependence (on) (syndrome), tobacco – see

dependence, drug, nicotine

Z71.6 Counseling (for), substance abuse, tobacco

Rationale: The acute respiratory insufficiency is a symptom that

is an integral part of the COPD and is not coded.

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Asthma Severity Frequency of Daytime Symptoms

Intermittent Less than or equal to 2 times per week

Mild Persistent More than 2 times per week

Moderate Persistent Daily.May restrict physical activity

Severe Persistent Throughout the day.Frequent severe attacks

limiting ability to breathe.

Source: Worldallergy.org

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Asthma

A 10 year old female child is being seen because of

severe persistent asthma with acute exacerbation.

What diagnosis codes are assigned?

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J45.51 Asthma, asthmatic (bronchial) (catarrh) (spasmodic), persistent,

severe, with exacerbation(acute)

Rationale: There are categories of the three degrees of persistent

asthma, with the ability to identify with or without exacerbation and status

asthmaticus.

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Thank You John F. Burns, CPC, CPMA, CPC-I, CEMC

Senior Consultant/Approved NAMAS Instructor

AHIMA Approved ICD-10-CM/PCS Trainer & ICD-10 Ambassador

(Phone) 518-796-7227 (Fax) 928-833-2267

jburns@namas.co

CEU Index #: 38878RDP